tbuckley/cabot-search huggingface dataset:
Telehealth closing racial/ethnic disparities? Increased adherence with remote symptom monitoring using patient-reported outcomes (PROs) among Black and Hispanic patients with telemedicine compared to in-person visits.
Authors: Ishwaria M Subbiah
Journal: Journal of Clinical Oncology (2022)

392 Background: Adherence with remote PROs in the real-world, non-clinical trial setting remains varied in pts with cancer. The rapid widespread telehealth into routine healthcare delivery raises concern for disparate impact on race/ethnic minorities. In this study, we sought to understand the impact of telehealth via electronic health record (EHR) on pt adherence with PRO-based remote symptom monitoring implemented through that same EHR portal. Methods: We queried a prospective institutional database of all PROs remotely delivered to our pts bw 1/1/18 - 12/31/21. Pts were divided into 2 time cohorts (pre-pandemic 1/1/18 to 3/31/20, mid-pandemic 4/1/20 to 12/31/21), their self-identified race/ethnicity, and age cohorts (AYA 15-39y, midage 40-64y, older adults 65y+). Then, one representative global symptom burden PRO measure used across different clinics was analyzed for completion in a representative month over 4 years, 2 pre- (Oct ’18, ‘19) and 2 mid-pandemic (Oct ’20, ‘21). We calculated descriptive statistics and compared (t-test, ANOVA) between time, race/ethnicity and age cohorts and independent variables. Results: Over 4 years, 93,875 unique patients received 1+ EHR-based remote PROs within their routine cancer care. Remote EHR-based PRO response rate almost doubled from pre-pandemic (35%, 12011 responders of 34742 pts) to mid-pandemic time (67%, 39812 of 59200 pts, p &lt; 0.00001). Analysis of one global symptom burden PRO widely used at our institution pre- and during pandemic showed the response rates rising (56.7% pre-pandemic vs 84.9% mid-pandemic, p 0.0004) with the sharp rise traced to 2 nd and 3 rd quarters of 2020 (response rate, 42.4% vs 85%, p &lt; 0.001), with the transition to telehealth. Within the representative 4m period, 2738 pts (1075 pts in 2 pre- &amp; 1663 in 2 mid-pandemic months) were sent that PRO – median age 60y, range 17-94y; 290 AYA 15-39y, 1444 midage 40-64y, 1004 older adults 65y+. PRO response rate increased (52% pre- to 81% mid-pandemic) w more responding without reminders from clinic team (13% pre-pandemic to 79% mid, p &lt; 0.001). Older adults saw the highest increases in PRO response rates up by 35% vs AYA up by 21% &amp; midage up 27%, p 0.012). Response rate without clinic reminders increased significantly (AYA, by 71%, midage by 78%, senior by 61%, p &lt; 0.00001). When further analyzing by visit type during pandemic, the increased PRO response rates are driven by telehealth where in-person PRO completion decreased by 19% (pre-pandemic 52%, during 33%) while pts who had an upcoming virtual visit had 94% PRO response rate (p &lt; 0.00001). Conclusions: Pt adherence w PRO-based remote symptom monitoring increased during the pandemic due to telehealth with the greatest gains seen in racial/ethinic minorities, inc. Black and Hispanic patients with cancer.
Price variability of pembrolizumab across U.S. National Cancer Institute–designated Cancer Centers (NCICCs) from 2016-2021.
Authors: S. M. Qasim Hussaini, Jordan Johnson, Fumiko Chino
Journal: Journal of Clinical Oncology (2022)

48 Background: NCICCs are poorly compliant to price transparency rules set forth by the CMS. Competitive price shopping is prevented due to a lack of uniform rate setting, and service charges are often higher than what a hospital reasonably expects to be reimbursed. We investigated variability in the charged and reimbursed payments for pembrolizumab utilizing Medicare claims across all NCICCs. Methods: Medicare claims data from 2016-2021 for pembrolizumab (HCPCS J9271) infusions in a hospital outpatient department were selected from the Definitive Healthcare claims database for all hematology-oncology and medical oncology providers at NCICCs. Average charges, reimbursements, and total claims were obtained. Annual percentage changes (APC) were calculated to evaluate trends during study period. Prices are presented as inflation adjusted numbers (charged and reimbursed; 2021 dollars). Analyses were performed in Excel (Microsoft Corp). Results: Our analysis included 53 NCICCs of which 47 were part of the 340B Drug Pricing Program (NCI-340B), 11 were Prospective Payment System-exempt (NCI-PPS), and 6 NCICCs were both (PPS/340B). From 2016 to 2021, total Medicare claims increased from 9461 to 46291 across NCICCs, with NCI-PPS centers comprising 30% of claims. Total payments to NCICCs increased from $55.9M to $388.1M annually. Average charge for pembrolizumab in 2021 were: $45,227 (NCI-PPS), $46,000 (all NCICCs), $49,057 (NCI-340B), $59,392 (dual-eligible PPS/340B). During study period, APC were: 9.2% (NCICCs), 9.6% (NCI-340B), 12.8% (NCI-PPS), and 17.5% (dual-eligible PPS/340B). Despite high charged prices, reimbursement was much lower, about 18.4% (or $7364) of charged price at NCICCs over study period. Highest reimbursement was noted at NCI-PPS (22%, or $8551), and lowest at NCI-340B (16.4% or $7086) over study period. When considering a smaller cohort of PPS-only or 340B-only, PPS-only status was associated with lowest charged price but highest reimbursement (33.5%, or $8568). Conclusions: NCICCs charged &gt; 4 times the average reimbursed price for pembrolizumab, with charges increasing faster than inflation. While lower charges were noted at NCI-PPS, they received higher reimbursement. Dual PPS/340B status commanded the highest charged prices and quickest price increases. Our study informs greater price transparency regulation at NCICCs and raises questions regarding utility of special status benefits from the federal government.[Table: see text]
Reducing the wastage of fresh frozen plasma in a hospital blood bank through the use of Six Sigma principles.
Authors: Robert Harrison Hester, Estella Castillo, Kelly Casteel, Lorenz Natividad, Fleur M. Aung, Fernando Martinez, Saroj Vadhan-Raj
Journal: Journal of Clinical Oncology (2022)

45 Background: MD Anderson Cancer Center is one of the largest users of blood products in the United States, with approximately 3,600 units of blood (PRBCs) transfused per month, and over 500 units of fresh frozen plasma (FFP) transfused per month. The wastage of blood products has both financial and patient care implications, as well as implications to donors. Decreasing blood product wastage is an institutional priority in terms of both resource utilization and cost savings. Methods: Outside metrics for the waste of blood products published by the American Association of Blood Banks (AABB) were compared to current data on the percentage wastage of blood products for fiscal year 2020. A dedicated project team set an aim to reduce the wastage of FFP by 25% from Q4 2020 to Q3 2021. Using Six Sigma principles, a run chart was developed to track units FFP ordered and transfused from October 2020 – March 2021. Minitab software was used to calculate mean FFP ordered, the upper confidence interval, as well as 2 standard deviations above the mean to determine a new maximum FFP thaw level. Results: The historical FFP “thaw level” was 32 units of FFP thawed per day. From October 2020 – March 2021, the average number of FFP units ordered per day was 8. The upper confidence level was 32, and 2 standard deviations was 24 units. After identifying 3 data points that were “out of control” and unrepresentative of actual usage, these values were adjusted to 7.5 units and 19.5 units, respectively. Based on this data, the daily thaw level was adjusted from 32 units per day to 20 units per day on June 21 st 2021. As of Q3 2021, this has resulted in a 40.7% decrease in the wastage of FFP. Conclusions: The application of Six Sigma principles was an effective way to identify variation in the ordering of fresh frozen plasma (FFP), and allowed for a sizeable reduction in the daily thaw level of this blood product. Post-intervention, there has been a dramatic decline in the wastage of FFP, resulting in cost savings for our institution and better stewardship of this scare resource.
Impact of the COVID-19 pandemic on patient perceptions of the quality of their cancer care.
Authors: Melanie Lynn Powis, Shabbir M.H. Alibhai, Alejandro Berlin, Rinku Sutradhar, Simron Singh, Saidah Hack, Monika K. Krzyzanowska
Journal: Journal of Clinical Oncology (2022)

286 Background: COVID has had a significant impact on how cancer care is delivered. Numerous modifications to care aimed at reducing in-person visits, and mitigating potential issues with staff and resource shortages were introduced, including the implementation of virtual visits. As many of the changes to cancer care are likely to persist beyond the pandemic, we undertook a survey to understand patients’ perceptions of the impact of the pandemic on the quality of cancer care that they received. Methods: We developed an electronic survey guided by the Picker Institute’s eight principles of patient-centred care. Patients &gt;18 years of age with a valid email address on file who have had a visit in the gastrointestinal clinic at Princess Margaret Cancer Centre (PM) in Toronto, Canada between 03/2020 and 05/2021 were recruited via email invitation in 10/2021 to anonymously participate. Logistic regression models were utilized to examine adjusted associations between demographic and clinical variables, and reporting a negative perception of care. Results: The response rate was 17.1% (438/2563); after excluding responses from those who are no longer patients and incomplete responses, 358 responses were included in the final analysis. Respondents were most commonly &gt;65 years of age (46.6%), male (48.6%), college/university educated (55.5%) and in follow-up phase of their disease (54.2%). Approximately half of respondents (56.1%) had some experience with care at PM prior to the pandemic, while the remaining patients were referred during. Most respondents (76.3%) indicated that, overall, they were satisfied with the care they received during COVID. Compared to patients who experienced care at PM prior to the pandemic, patients referred during COVID were 2.5 times more likely to believe that patients received worse care during COVID than those treated prior (OR: 2.42; 95% CI: 1.08-5.44). Most respondents (69.5%) reported that virtual appointments positively impacted the quality of their cancer care. Adequacy of emotional support was the most negatively perceived dimension of patient-centred care, whereby 18.7% of patients felt they were provided with inadequate information on support services available to them, and 17.6% felt that they had received inadequate support. Relative to those in follow-up, patients with a newly diagnosed cancer were more likely to report receipt of inadequate emotional support (OR: 5.69; 95% CI: 2.18-14.82). Conclusions: Most patients reported being satisfied with the quality of care provided to them during COVID and reported a positive impact of virtual appointments on their care. Future quality improvement efforts should focus on how to improve dissemination of information on available support services and access to appropriate emotional supports, particularly for newly diagnosed patients.
Real-world racial disparities in EGFR testing and third-generation EGFR TKI use among U.S. patients with stage IV NSCLC.
Authors: Elizabeth Sacchi, You Li, Vincent A. Miller, Melissa D. Curtis, Siraj Mahamed Ali
Journal: Journal of Clinical Oncology (2022)

124 Background: Biomarker testing for EGFR mutations (EGFRm) is recommended for all newly diagnosed patients with metastatic NSCLC. Third-generation EGFR TKIs are the recommended standard-of-care therapy for patients with EGFRm+ NSCLC regardless of race, although EGFRm occur more frequently in Asian patients (Table). We investigated the association between race, EGFR testing and receipt of subsequent first-line (1L) treatment with the third-generation EGFR TKI, osimertinib. Methods: This retrospective, observational study used the nationwide Flatiron Health EHR-derived de-identified database. Adults with an initial diagnosis of stage IV NSCLC who initiated systemic 1L therapy between Apr 2018 (osimertinib approval) and Feb 2022 (data cutoff date) were eligible. Two cohorts were defined: those eligible for EGFR testing, and those EGFRm+ patients eligible for 1L osimertinib. Multivariable logistic regression was used to investigate odds of 1) EGFR testing, and 2) 1L osimertinib use, by race. Random-effects logistic regression was used as a sensitivity analysis to evaluate the impact of inter-practice variation on each outcome. Confidence intervals (CI) were calculated at 95%. Results: 9,505 patients were eligible for EGFR testing. After adjustment, Asian patients were nearly twice as likely to be tested (adjusted odds ratio [aOR]: 1.93, CI: 1.33 – 2.89, p = 0.0001), while Black patients were 25% less likely to receive testing (aOR: 0.75, CI: 0.62 – 0.90, p = 0.002), both relative to White patients. Including a random factor of practice attenuated the effect of race for Asian patients (aOR: 1.74, CI: 1.15 – 2.64, p = 0.0009) as well as Black patients (aOR: 0.8, CI: 0.65-0.97, p = 0.021). Of these patients, 1,247 were confirmed EGFRm+ and were thus eligible for 1L osimertinib. Asian patients were marginally more likely to receive 1L osimertinib, even after adjustment ( aOR: 1.51, CI: 0.958 – 2.43, p =.082). The inclusion of a random factor of practice diminished the marginal effect of race ( aOR: 1.46, CI: 0.90 – 2.36, p = 0.1). Conclusions: Retrospective analyses using real-world data revealed differences across races in EGFR testing among patients with stage IV NSCLC, suggesting disparities in quality of care. Racial disparities were also observed in 1L osimertinib use among patients with EGFRm+. Sensitivity analyses suggest that these disparities may partially be attributed to differences in care between practices. Future studies are warranted to further characterize this unexpected race-based difference in biomarker testing and treatment initiation. This work highlights the need for investigations of racial disparities in access to both biomarker testing and effective treatment options across precision oncology.[Table: see text]
Falling off the treatment wagon: Barriers to cancer treatment and care for people experiencing health and social inequities.
Authors: Amber Bourgeois, Ashley Mollison, Tara C Horrill, Leah Lambert, Kelli Stajduhar
Journal: Journal of Clinical Oncology (2022)

135 Background: A key pillar of Canada’s healthcare system is universal access, yet significant barriers to cancer services remain for those impacted by health and social inequities (e.g., poverty, homelessness, racism). For this reason, cancer is diagnosed at a later stage, resulting in worse patient outcomes, a reduced quality of life, and at a higher cost to the healthcare system. Those who face significant barriers to access are under-represented in cancer control services Consequently, these inequities result in people dying from cancers that are highly treatable and preventable, however; little is known about their treatment and care course. The aim of this study was to explore barriers to accessing cancer treatment among people experiencing health and social inequities within a Canadian context. Methods: We conducted a secondary analysis of ethnographic data informed by critical theoretical perspectives of equity and social justice. The original research draws from 30 months of repeated interviews (n = 147) and 300 hours of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers. Results: Our analysis identified four themes presenting as ‘modifiable’ barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment (2) health literacy and ‘missing the window’ for shared decision making (3) invisibility of the social/structural determinants of health (4) navigating a complex and fractured system. These inter-related themes point to how people impacted by health and social inequities are at times ‘dropped’ out of the cancer system and therefore unable to access cancer treatment. Conclusions: Findings make visible the contextual and structural factors contributing to inequitable access to cancer treatment within a publicly funded health care system. Identifying people with social and health inequities and approaches to delivering cancer services are explicitly equity-oriented are urgently needed.
Disparities in overall survival (OS) outcomes based on treating facility volume in pancreatic neuroendocrine tumors.
Authors: Sri Harsha Tella, Anuhya Kommalapati, Aakash Desai, Patrick Walsh McGarrah, Timothy J. Hobday, Thorvardur Ragnar Halfdanarson
Journal: Journal of Clinical Oncology (2022)

150 Background: Pancreatic neuroendocrine tumors (pNETs) comprise less than 5% of all pancreatic tumors and 7% of all neuroendocrine tumors (NETs). There has been considerable progress in understanding the biology of pNETs and numerous therapeutic options emerged, especially with the collaboration of various specialties in the multidisciplinary setting. In this this study, we sought to analyze the association of facility volume, treatment modalities offered, and different risk adjusted outcomes in pNETs. Methods: We extracted data from National Cancer Data Base (NCDB) that covers 70% of all newly diagnosed cancer cases in the U.S and Puerto Rico. Patients with pNETs diagnosed between 2004 &amp; 2017 were included and classified into tertiles based on hospital volume. Volume–outcome relationship was determined by using Cox regression adjusting for patient demographics, comorbidities, tumor characteristics, insurance type and therapy received. Kaplan Meier estimates of OS were compared with log-rank test. The primary predictor of interest was the facility volume defined as number of pNETs treated/year. A total of 7202 patients with pathologically confirmed pNETS were treated at 840 facilities. The median annual facility volume was 5patients/year. Facilities were classified into (T:mean cases/year) T1: &lt; 3; T2:4-8; T3:≥9 cases/year. Results: A total of 7202 pNET patients were treated at 840 facilities. The median annual facility volume was 5 patients/year. Facilities were classified into (T: mean cases/year) T1:&lt;3; T2:4-8; T3:≥9 cases/year. The unadjusted median OS by facility volume was: T1: 71 months (m), T2: 136 m, and T3: not-reached (p &lt; 0.001). On multivariable analysis, compared with patients treated at T3 facilities, patients treated at lower-tertile facilities had higher risk of death [T2 hazard ratio (HR), 1.17 (95% CI, 1.03-1.33); T1 HR, 1.45 (CI, 1.30-1.67), p &lt; 0.0001] and such a difference in OS was more pronounced in stage IV disease (Table). Patients at T3 facilities (vs T1) were more likely to receive surgical resection of the primary tumor (75 vs 49%), lymph node dissection performed at the time of surgery (70 vs 42%), and a better R0 resection (72 vs 46%) (p &lt; 0.01). Conclusions: Patients who were treated for pNETs at high-volume centers (&gt; 9cases/year) had significantly higher OS and were more likely to receive surgical resection along with lymph node dissection and R0 resection. There was a 45% increased risk of death in patients treated at low volume centers (&lt; 3/year) as compared to high-volume centers (&gt; 9/year). While OS difference was noticed in all stages, the difference was more pronounced in stage IV disease demonstrating the importance of multi-disciplinary approach in pNETs management and incorporating such quality measures in low-volume facilities.[Table: see text]
Opportunities to improve care for patients with peritoneal carcinomatosis and their caregivers.
Authors: Rachel A. Pozzar, Anna Tavormina, Andrea Catherine Enzinger, Hanneke Poort, Andrea Demarsh, Madeline Gorra, Mary E. Cooley, Alexi A. Wright
Journal: Journal of Clinical Oncology (2022)

207 Background: Cancers of the gynecologic and gastrointestinal tracts (GYN/GI) often metastasize along the peritoneum (peritoneal carcinomatosis; PC), causing ascites and malignant obstructions of the bowel, urinary tract, and biliary tree. Patients with PC frequently require palliative surgical interventions; e.g., ostomies, gastric tubes, and catheters. To date, few researchers have described the unique needs of these patients and their caregivers. Methods: We recruited adult patients with advanced GYN/GI cancers, a recent hospitalization for PC, and a new complex care need. We invited adult caregivers of enrolled patients to participate. We abstracted patients’ clinical characteristics and outcomes from the medical record. At baseline, patients completed items related to perceived health status and advance care planning, while caregivers completed the Caregiver Reaction Assessment (CRA) and items related to their caregiving role. All participants completed the Hospital Anxiety and Depression Scale. Results: Sixty-five patients and 40 caregivers completed surveys. Fifty-six (86%) patients had GYN and nine (14%) had GI cancers. Most (56/65, 86%) were re-hospitalized within two months, and over a quarter (18/65, 27%) died within six months of enrollment. Twenty-four (37%) reported they were terminally ill, but only nine (14%) had spoken with a physician about the care they would want to receive if they were dying. Caregivers were primarily spouses (27/40, 70%) who provided most or all of the care for their loved one (25/40, 63%) and engaged in caregiving seven days per week (27/40, 68%). Of the four CRA subscales measuring negative caregiving experiences, mean scores were highest for impact on schedule (3.3, SD = 0.8; possible range 1-5, higher scores indicate greater burden), followed by impact on finances (2.3, SD = 1.1), impact on health (2.0, SD = 0.65), and lack of family support (1.8, SD = 0.67). Caregivers reported that they received training on a mean of 1.1 (SD = 1.3) clinical care tasks but performed a mean of 2.9 (SD = 1.7) clinical care tasks. Thirty-two (49%) patients and 9 (23%) caregivers met borderline case or case criteria for depressive symptoms, while 26 (40%) patients and 15 (38%) caregivers met borderline case or case criteria for anxiety symptoms. Conclusions: Patients with PC and their caregivers are highly burdened and distressed. Patients are at high-risk for re-hospitalization, but few have discussed their end-of-life wishes with their medical teams. Interventions that train these patients and their caregivers to perform clinical care tasks, facilitate serious illness conversations, and provide psychosocial support are needed. Clinical trial information: NCT03367247.